Update on ACA Legal Status

The U.S. Supreme Court is set to decide whether to expedite a review of Texas v. United States, the court case challenging the constitutionality of the Affordable Care Act (ACA). A ruling in favor of the plaintiffs would invalidate the entire law, leaving an estimated 20 million people uninsured ahead of the November 2020 elections.

How did we get here?

In 2018, Texas Attorney General Ken Paxton, leading a coalition of Republican attorneys general and two Texas residents, challenged the constitutionality of the ACA in court. The plaintiffs argued that since the ACA’s individual mandate penalties were eliminated with the Tax Cuts and Jobs Act of 2017, the entirety of the ACA cannot operate and therefore should be invalidated.

The case was decided by the Court for the Northern District of Texas, where the judge ruled in favor of the plaintiffs and held that the entire ACA was unconstitutional. The case was appealed, and in December 2019, the U.S. Court of Appeals for the 5^th Circuit ruled 2-1 that the individual mandate portion of the law was unconstitutional but did not decide on the larger question of whether or not that meant the entirety of the ACA should be invalidated. They sent the case back to the District Court for further ruling. In response to this latest decision, a group of Democratic attorneys general led by Xavier Becerra of California requested an expedited review of the case by the U.S. Supreme Court.

Options for the Supreme Court

While the Democratic attorneys general have asked for an expedited review, the plaintiffs and the Trump Administration have argued that this review would be premature.

The Supreme Court now has three options:

• Expedited review: Five Supreme Court justices would have to agree to move forward with an expedited review. Some experts think this is possible with Chief Justice John Roberts joining the court’s four liberal justices.
• Regular review: Another option is that they accept the case, but on their regular schedule. This means the case may not be heard until the fall, potentially after the elections. This would only require four justices to agree to review the case.
• Reject the request: If the Supreme Court rejects the request entirely it would go back to the lower courts who will continue their work on a regular schedule. This case may still eventually get to the Supreme Court, but on a much longer timeline.

 Consequences of Repealing the ACA

According to an estimate by The Urban Institute, a ruling to invalidate the Affordable Care Act would lead to an increase of 20 million uninsured people, a 65 percent increase in the number of nonelderly people without insurance coverage. Certain populations who gained coverage with the ACA would be hit the hardest by this change, including those with incomes below 200% of the federal poverty level, young adults, and residents in the South and West.

In addition to the loss of insurance coverage, many other facets of the law would be subject to elimination affecting millions living with mental illnesses and addictions and the providers who serve them. Potential changes include:

• Adults who lose Medicaid coverage would lose access to preventative screenings, medications, and mental health services
• Insurance companies could stop covering substance use disorder treatment and funding for opioid treatment in Medicaid could significantly decrease
• Americans with preexisting conditions could pay higher premiums or be disqualified from buying certain insurance plans
• Over 150 million people may face increased out-of-pocket costs as employer- or ACA-based insurers will not be limited by caps
• Medicare beneficiaries may have to pay more for preventative care visits and the cost of their prescription drugs could increase

The National Council will continue to monitor the case’s progress and advocate to protect coverage for individuals seeking mental health and addiction services.